This is a copy of application to conduct a not-for-profit applicaion

1. CG-AR, APPLICATION FOR ANNUAL RAFFLE FIRST TIME APPLICANTS
State Form 53635 (R/7-08) For Official Use Only
INDIANA GAMING COMMISSION License Fee Paid
Approved by State Board of Accounts, 2008 Reset Form Date Received
Reviewed By
Date Entered
INSTRUCTIONS: Processing of this application can take up to 120 days. Attach License Fee.
1. Name of organization (please type or print) 2. Email address
3. Previous name of organization (if name changed) 4. Federal Identification number (FID)
5. Address of principal office (number and street) Contact name 6. Business hours
City State ZIP code County Daytime telephone number
( )
7. Address of the facility where the event will be conducted (number and street) Doing business as (DBA)
City State ZIP code County Daytime telephone number
( )
FACILITY/TANGIBLE PERSONAL PROPERTY INFORMATION
Attach additional sheets if necessary to supply all information for each line.
8. Does your organization own _____, lease (rent) _____, or use a donated _____ facility where the licensed event will be conducted? (Check one)
• If leased (rented) or donated, enter name and address of lessor or donor and attach a copy of your signed lease or donation agreement.
Name of lessor/donor (full legal name) Address (number and street)
City State ZIP code County Daytime telephone number
( )
9. Is any tangible personal property (i.e. tables, chairs, etc.) or gaming equipment or device being leased or donated to you for this event? Yes No
If you answered Yes, list the name and address of the lessor or donor. Attach a signed copy of the lease or donation agreement.
Note: Gaming equipment or devices must originate from a licensed distributor and/or manufacturer.
Name Address (number and street) City State ZIP code
Manufacturer and Distributor Information
Attach additional sheets if necessary
10. List the manufacturer(s) and/or distributor(s) from whom you intend to purchase licensed supplies.
Name Address (number and street) City State ZIP code Items
11. Does your organization own gaming equipment or devices? Yes No
If yes, list the distributor/manufacturer's name, date of purchase, purchase price, and type of equipment or device purchased.
Name of distributor/manufacturer Date of purchase Purchase price Type of equipment/device
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2. Operator Information
Attach additional sheets if necessary
12. List below at least three (3) operators who will supervise, manage, and be responsible for the operation and conduct of the gaming event.
Full legal name Home address Driver’s license or Date of birth Daytime telephone Years with Check
(number and street, city, state, ZIP code) state I.D. (month, day, number organization appropriate
year) box
Bartender
Member
( )
Bartender
Member
( )
Bartender
Member
( )
13. Please list the name from above of the principal operator who has overall responsibility for the operation and control of this
charity gaming event. Please type or print.
X
Name Daytime telephone number
14. Are any of the operators listed above also operators for another organization's charitable gaming events? Yes No If yes, attach a list
including each individual’s name, name of organization, and the month(s) that they will operate other gaming events.
Worker Information
Attach additional sheets if necessary
15. List all individuals (excluding operator information above) who will assist and work in the operation of the licensed event.
Full legal name Home address Driver’s license or Date of birth Daytime telephone Mos./years Check
(number and street, city, state, ZIP code) state I.D. (month, day, number with appropriate
year) organization box
Bartender
Employee
( ) Member
Bartender
Employee
( ) Member
Bartender
Employee
( ) Member
Bartender
Employee
( ) Member
16. Have any operators or workers listed on line 13 and 16, or on any attachments, been convicted of a felony within the past 10 years in any
jurisdiction? Yes No If you answered Yes, attach a list including each name, type and date of conviction, and jurisdicition/court.
Gross Retail Sales Information
(Example: concessions, daubers, snacks, etc.)
17a. Will you be conducting any type of retail sales during the licensed event (i.e. accessories, concessions, etc.)? (Check one) Yes* No
*If you answered “Yes” complete the following information. If the seller is required to have a Retail Merchant Certificate, enter that number in the box
provided.
Name of organization offering the sales Retail merchant certificate number
17b. Which of the following will your organization be receiving? (Check one)
All of the retail sales income A flat fee retail sales payment
A percentage of the retail sales income Other (explain)
Additional Activities Authorized
18. Will your organization be selling pull tabs, punchboards and/or tip boards? Yes ___ No ___
Will your organization be conducting a door prize drawing at this event? Yes ___ No ___
(Limitation on door prize drawings at all events is $1,500 and cannot be increased)
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3. Financial Information
19. Where will the charity gaming financial records be maintained?
Address (number and street)
City State ZIP code
20. Name, address, and telephone number of the person maintaining these records.
Name Address (number and street)
City State ZIP code Daytime telephone number
( )
21. List the organization's separate and segregated charity gaming checking account information.
Name of bank
Address (number and street)
City State ZIP code
Name of separate and segregated charity gaming checking account Account number
License Fee Information
22. The license fee for an organization’s first Annual Raffle License is $50.00 and must be paid with this application. The fee should be paid by a check
drawn from your separate and segregated charity gaming checking account. Make your check payable to: Indiana Gaming Commission.
Certification
23. We certify under penalty of perjury that there are no misrepresentations or falsifications in the information stated. We understand false or misleading
statements will cause rejection of this application or revocation of future license(s).
Signature of Presiding Officer Print name Title Daytime telephone number Date (month, day, year)
Signature of Secretary Print name Daytime telephone number Date (month, day, year)
Send this application and $50.00 fee to:
Indiana Gaming Commission
Charity Gaming Division
101 W. Washington St., East Tower, Suite 1600
Indianapolis, IN 46204
Phone: (317) 232-4646
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